For one, I think our threshold for risk is higher than others in terms of exposure in the field, and in terms of testing innovations, especially in situations where there are no other good therapeutic options. Sleeping sickness is a good example; the existing treatments were so toxic that we had to move on, to try to invent new things.

So we accept a dimension of risk. But we do not transfer risk to other organizations or subcontract to other groups because we think there is too much risk for our own staff. The fact that we are so uncomfortable with the remote control approach, where projects are managed from afar, is a sign that we don’t want to just transfer risk. If it’s our project, it’s our risk, and it’s our responsibility.

The majority of the leadership has field experience, too. Not all organizations can say that.

MSF has reconfirmed its associative nature at every stage of its history. As a result, MSF’s leadership is different from other organizations. It’s clearer in the US, where the board is also composed mostly of medical people and people with field experience. This has an impact on the way the association is governed. There are advantages and disadvantages, to be frank. People with extensive field experience can find it challenging to work at the macro level of the organization and not to be involved in daily operations, and more experts from outside fields might provide new input and new ideas. But at the same time, the field experience at the top of the organization is the best guarantee that decisions will first and foremost serve the needs of operations, of the teams on the ground.

How does the US office interact with the rest of the movement?

Formally, we interact through platforms at the group and international level, where peers meet and work on agreed-upon agendas. This could be a meeting of the Directors of Communications, or a meeting of the Field Human Resources directors. There is a Director General platform, and a core Executive Committee, which I’m a part of.

MSF-USA also has fiduciary responsibilities that are set together with the board and the program committee and then reviewed in highly formal exercises. Likewise, if we have received funding from a specific foundation for a specific project, we will consult with the operational center in charge of the project so we can report back to the donor about how and where their pledge is being used.

Then there are more informal contacts between people in different offices at all different levels. It could be when the operational centers want us to organize advocacy rounds with representatives of the United Nations or the US government. It could be between fundraising teams discussing different campaigns and priorities, or between communications teams. It could be related to the 400 people the US office sent to field projects last year, pairing them with specific programs, or getting requests from programs that our Field HR team then tries to fill. The examples are numerous.

When we open projects, are there specific things we look for?

There must be a need for and an added value in MSF’s presence. If we don’t feel there is an added value, or if we feel anybody could do it, we’re not going to do it. And we wouldn’t do it if it’s not in the scope of our main ambitions— working in unstable situations, on acute medical issues, with neglected populations, when there is a gap that is not being filled. If those conditions are there, then the question becomes whether we have the means and the access, what the security issues are, and so forth. But this only happens after we’ve determined that it makes sense for us to work there based on what MSF is and what it does.

Do governments influence when and how we work?

Being independent doesn’t mean we do not listen. Whenever we can, we try to establish a sort of partnership with the government in a country. We want to be useful, so we welcome their ideas of where the needs are. The decision to open will be based on the combination of how we reconcile the needs they feel they have, the needs we think they have, and our ability to respond to these needs.

They never force us to work somewhere. This is why we are independent—we can always decide not to do something. But we welcome the government’s requests or ideas in terms of geography or in terms of needs. And then independence is really about deciding on our own if this is something that matches what we consider is within our mission, expertise, and capacity.

Can others influence things like whether we have women in our projects, or people from certain nationalities?

No, I don’t think that this is a line that we are ready to cross. We are very practical. There are countries where we know we won’t have a single patient in the maternity ward if there are no female doctors. We adapt to those realities so we can provide the best possible care. But it would never be a directive from someone else.

The same for nationalities. If it might compromise our security or effectiveness, we might not send people of certain nationalities to certain countries. We did so in Mali. And for many years we didn’t send Americans to Afghanistan. But we do not let others tell us when and where we can do this. It’s based on practicality and keeping in mind our ultimate purpose: to serve the patients who need assistance.

How do we avoid being confused with international forces or other government-funded organizations?

We concluded in recent years that it was more effective for our security and our recognition to expose our logo on cars, on our clothes—to be visible rather than very discreet. This is what the International Committee of the Red Cross (ICRC) did in Pakistan and we felt it was more effective than trying to keep a lower profile. It gives the population a clearer sense of who we are, and it gives us a clearer sense of whether any issues specifically are directed at us. It also comes from the requests of the factions we negotiate with in different places. They often ask us to be highly visible so they don’t confuse us with any other group or faction.

We also limit our visible interactions with international forces. We try not to go out at night with UN peacekeepers and have drinks and this kind of stuff. And we try to have our own transportation, and to have our cars and individuals clearly identified.

Speaking of security, might we return to Somalia?

I hope so. We’ve tried to avoid the mistake we made with Afghanistan in 2004, which was losing complete contact with the country when we left after our colleagues were assassinated. That made it hard to come back, because we had to start from square one. With Somalia, we have kept a team in Nairobi to monitor and analyze the situation and to keep contact with parties inside the country, so we’ll know if there are any new trends that might make us reconsider our decision.

Are there any issues that aren’t on the agenda right now that might be in five or ten years?

The availability of water could be a very serious issue. Other issues we’re already seeing: the fact that there are medical issues for which there is either limited research or for which the research and science is unaffordable. Hepatitis C will remain a problem until it’s solved; the same for drug-resistant tuberculosis. Resistance to malaria treatment is going to be an issue; we know that already. That will be a big one, resistance to malaria and antibiotic-resistant infections in general.

Global warming—natural disasters are much larger than they used to be. But MSF’s role is not always clear, because natural disasters do not necessarily occur in resource limited settings. If they occur in countries like Japan, or in certain parts of the US, our added value would be extremely limited. That’s why it’s hard for me to make a link between global warming and MSF, unless it occurs in very resource limited settings.

You deal with a lot of bad news. What keeps you coming to work every day?

Looking at the three major crises of the moment, South Sudan, Central African Republic, and Syria—or let’s say four, because we should include Democratic Republic of Congo, which is a forgotten crisis—the humanitarian needs are huge and there are no political solutions in sight. So, yes, the circumstances are very depressing. But they also make humanitarian action so meaningful, because it is the only hope that people have. It is the only possible response. If you have no political solution in sight, at least you can help people survive until the political landscape improves, or in case it improves. It is depressing, but at the same time, there’s nothing more useful for these populations, at this stage, than some of the things we can provide: medical care, water, food. If the situation stabilizes, they will have different priorities—cultivating their lands or going to school or getting a job. But for the moment, for a refugee from Syria, or in Syria, or someone in parts of CAR or DRC, it’s really about surviving.